Enhanced premium tax credits have expired, and the exchange coverage those credits helped pay for is starting to disappear. For many patients, the plan they had last year is no longer an option.
Providers are already feeling this shift. Several large, publicly traded health systems reported financial hits in the second quarter, and one industry estimate puts the potential revenue loss for hospitals at $68.6 billion over 2026 and 2027. Patients haven’t gone anywhere, though. They’re still walking up to registration desks and into EDs every day, still needing care, just without a payer behind them.
For providers, a share of that lost revenue is recoverable. It comes down to identifying the patients who still qualify for Medicaid or other assistance, connecting with them before care begins, and doing it at a scale that manual work can’t match.
Steady enrollment, shrinking coverage
On paper, this year looks steady, with 23.1 million people enrolling in exchange plans during the Open Enrollment Period, which is near last year’s record-breaking total. However, sign-ups fell by more than one million from the year before, making it the sharpest annual decline since the marketplaces first opened.
Enrolling in a plan isn’t the same as keeping a plan, and the number of people who continue paying their premiums is also expected to slide toward 16.5-17.5 million, down from 22.3 million in 2025. The gap between who signed up for coverage and who can afford to continue it can provide a clearer picture of how many people are actually losing coverage.
The strain is being felt most acutely in a few states. Florida, for example, has around 4.5 million marketplace enrollees, more than any other U.S. state. Whether a given patient still qualifies for Medicaid or other assistance depends on the state they live in and their income, and their eligibility changes as their income does. The people who still qualify are often the hardest to identify, and many of them aren’t in a position to figure it out on their own.
Eligible, but going unchecked
Many patients showing up for care without insurance still qualify for Medicaid or another form of assistance. Some may have had a change in income, while others never knew they qualified in the first place. A sizeable share of that lost coverage can be recovered if someone identifies it in time.
Right now, that identification is a mostly manual process, requiring staff to research eligibility one patient at a time. As the volume of uninsured patients grows, more of them are slipping through the cracks. Those patients are then billed as uninsured, and visits turn into uncompensated care.
Nationally, uncompensated care is on track to climb from $32.4 billion to $44.9 billion. Much of that total represents care delivered to patients who qualified for coverage that no one went looking for, and recovering even part of it is the upside providers are chasing now.
Catching coverage before the visit
Providers who see this problem now are working to catch coverage before it slips away by moving eligibility checks to the front of the visit, screening patients before or as they arrive rather than researching each one individually.
This pays off for both sides. Patients who likely qualify for Medicaid or other assistance learn about coverage they didn’t know they had, and providers bill a payer instead of writing off the balance.
Tools to do this at scale are already available today. Some solutions run eligibility screening in the background, using current eligibility data to flag likely Medicaid qualification as soon as a patient registers, without pulling staff away from patient care.
Choosing the right partner comes down to a few practical questions:
- Can it accurately identify eligibility when a patient registers?
- Does it work inside the registration and revenue cycle tools your team already runs, rather than bolting on another system to check?
- And can it hold up at volume, since the goal is to do automatically what staff can’t keep up with manually?
Find a partner who gets the answers to those questions right, and the manual scramble to catch eligibility can turn into something that runs in the background on its own.
Turning the coverage cliff into a coverage conversation
Patients are going to keep showing up for care without coverage. Coverage loss at a large scale will change who comes through the door and how they pay, and that will be true even after the next policy debate.
The organizations who manage this well will treat each uninsured patient as an open coverage question, then put the tools in place to answer it before a patient receives a bill. When it works, the patient gets the coverage they were owed all along, the provider keeps revenue they’d otherwise have written off, and staff gets time back in their week.
In a difficult moment marked by what patients are losing, handing coverage back to patients is a rare win, and it’s within reach for any organization ready to act on it.
About Casey Williams
Casey Williams has twenty years of experience in developing customized patient communications and payment solutions to build a strategic patient engagement initiative for over 100 healthcare revenue cycle clients. He has held various leadership positions within HFMA, AAHAM and COPAM.
Casey’s knowledge of patient engagement strategies, including modifying patient behavior and self-service optimization, has made him a go-to speaker/presenter for HFMA, Healthcare Finance Institute, and Litmos Healthcare Division (formerly Bridgefront) to name a few. He is the co-author of Reinventing Revenue Cycle Management: Delivering Next-Level Patient Experiences and has also been published in Becker’s Hospital Review and Executive Insight magazine.
